Health Screening Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0596-0164 can be found here:

Documents and Forms

Document Name Document Type
Form FS-5100-31 Health Screening Questionnaire Form
FS-5100-31 Health Screening Questionnaire 5100-31 updated June 2009.rtf www.fs.fed.us/fire/safety/wct/2006/5100-31.pdf Form
FS 5100-30 Work Capacity Test - Informed Consent REV fs_5100_30.doc www.fs.fed.us/fire/safety/wct/fs_5100_30-1.rtf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Screening Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FS-5100-31	Health Screening Questionnaire	5100-31 updated June 2009.rtf	http://www.fs.fed.us/fire/safety/wct/2006/5100-31.pdf	Yes	No	Fillable Printable
Form	FS 5100-30	Work Capacity Test - Informed Consent	REV fs_5100_30.doc	http://www.fs.fed.us/fire/safety/wct/fs_5100_30-1.rtf	Yes	No	Fillable Printable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,397	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,794	242	10,552
Annual IC Time Burden (Hours)	896	20	876
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.